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							EMPORIA STATE UNIVERSITY Graduate Studies Credit Card Approval Form

Student ID __________________________________________________________________ Name ______________________________________________________________________ Cardholder Name ____________________________________________________________ Cardholder Address __________________________________________________________ City _______________________________ State ___________ Zip Code ________________ Email address:__________________________________ Phone:_______________________

APPLICATION FEE
Masters, Licensure, Certificate, Non-Degree $40 P.h. D. $50 Thesis ________

CREDIT CARD INFORMATION
Credit Card Type (Check one) Visa Mastercard Discover

Account Number ________________________________________________________ Expiration Date _________________________________________________________ Signature _______________________________________________________________ Please complete all information and be sure to include signature.

RETURN FORM TO: Emporia State University Graduate Studies and Research 1200 Commercial Emporia, KS 66801 OR Fax 620-341-5909